comparison of dual task and task oriented training...

International Journal of Neurologic Physical Therapy 2019; 5(2): 42-50

http://www.sciencepublishinggroup.com/j/ijnpt

doi: 10.11648/j.ijnpt.20190502.13

ISSN: 2575-176X (Print); ISSN: 2575-1778 (Online)

Comparison of Dual Task and Task Oriented Training Programme on Gait in Chronic Stroke

Amandeep Singh1, 2, *

, Davinder Kaur1, 2

, Rajneet Kaur Sahni1, 2

, Simran Grewal1, 2

1Physiotherapy Department, All Saints Institute of Medical Science and Research, Ludhiana, India 2Baba Farid University of Health Sciences, Faridkot, India

Email address:

*Corresponding author

To cite this article: Amandeep Singh, Davinder Kaur, Rajneet Kaur Sahni, Simran Grewal. Comparison of Dual Task and Task Oriented Training Programme on

Gait in Chronic Stroke. International Journal of Neurologic Physical Therapy. Vol. 5, No. 2, 2019, pp. 42-50.

doi: 10.11648/j.ijnpt.20190502.13

Received: August 30, 2019; Accepted: September 25, 2019; Published: October 20, 2019

Abstract: Stroke is the major cause of disability and handicap in adults and it usually results in some degree of muscle

weakness. Daily living requires balance and walking ability while performing tasks. Several factors affect the functional

independence in post stroke period in which gait plays a significant role. 30 subjects of age group 45-60 years were selected by

purposive sampling and informed consent was taken. The subjects were divided into 2 groups A and B of 15 each. Both the

groups received conventional physiotherapy as muscle strengthening of affected lower limb and balance training. Group A

received dual task training and Group B received task oriented training for 8 weeks. Pre test and post test data for gait

parameters (gait speed, cadence, step length, stride length) were obtained by using 10meter walk test respectively. Unpaired‘t’

test was applied at the p<0.05 for the comparison within and between the groups for the variable Gait Parameters(i.e gait

speed, cadence, step length, stride length). The values of gait parameters between the groups were significant which showed

that task oriented training is more effective than dual task training to improve gait in chronic stroke.

Keywords: Stroke, Dual Task Training, Task Oriented Training, Gait, 10-Meter Walk Test

1. Introduction

Stroke is an acute onset of neurological dysfunction due to

an abnormality in cerebral circulation with resultant signs

and symptoms that corresponds to involvement of focal areas

of the brain. World Health Organization (WHO) classified

stroke as “neurological deficit which must persist for at least

24 hour duration. [7] Stroke is the third most commonest

cause of death in India according to the statistics. [1]

Approximately 80 percent of strokes are due to ischemic

cerebral infarction and 20 percent to brain hemorrhage. [2]

An acute space occupying lesion which compresses,

displaces and disrupts the surrounding tissue which causes an

increase in intracranial pressure and may lead to herniation

which ultimately resulting in edema formation, aggravation

of the intracranial pressure rise, and risk for herniation. [3] In

post stroke patients, the function of cerebral cortex becomes

impaired, while that of the spinal cord is preserved. The

complex interactions of the neuromusculoskeletal system

should be considered when selecting and developing

treatment methods that should act on the underlying

pathomechanisms causing the disturbances. The spinal cord

generates human walking, and the cerebral cortex makes a

significant contribution in relation to voluntary changes of

the gait pattern. [4] Movement involves not only motor skills,

but is also reliant on sensory and cognitive systems. There is

also evidence that some older people stop walking when they

talk and that this phenomenon predicts susceptibility to

falling. [5] A variety of physiotherapy interventions improve

functional outcomes, even when applied late after stroke.

These findings challenge the concept of a plateau in

functional recovery of patients who had experienced stroke

and should be valued in planning community rehabilitation

services. [6] Trunk rehabilitation exercises, balance training,

muscle strengthening is essential for post stroke patients for

International Journal of Neurologic Physical Therapy 2019; 5(2): 42-50 43

recovery of balance and improvement in gait and is an

important component. [7] Many therapeutical approaches for

rehabilitation of gait are useful after stroke. Out of which

dual task (DT) training and task oriented training programme

are being used. Cognitive-motor and motor dual tasks play

important roles in daily life: walking while talking, using a

mobile phone, carrying a bag or watching traffic. It has been

suggested that dual task training might have greater efficacy

for improving dual task performance compared to single task

training. [8, 9] Gait related dual task deficits persist in

community dwelling stroke survivors many months after

discharge from rehabilitation. [10] Task oriented training

involves a variety of practices to help patients derive optimal

control strategies for solving motor problems. During task

oriented training, many types of movement are practiced, to

limit compensatory movements and increase adaptive

movements. [11] It is a method which focuses on specific

functional tasks associated with the musculoskeletal and

neuromuscular systems and gait related tasks are practiced

using a functional approach. [12] Task oriented training

induce greater improvement in walking competency in

people with stroke. [13]

Achievement of community ambulation after stroke is

critical for active participation in everyday activities

preventing social isolation and depression and enhancing

quality of life. Despite initial improvements in motor

function in individuals early post stroke, patients often

demonstrate a “plateau,” or deceleration of motor recovery in

the chronic stages. Several previous studies have proven that

dual task training and task oriented training improve the gait

through improvement in gait speed, cadence, step length,

stride length in stroke patients. But till date no evidence is

available on the basis of peer review of articles which

determine that out of dual task training and task oriented

training which is more beneficial. The current study focus is

to determine the most effective training out of above

mentioned protocols for improving gait in chronic stroke.

2. Main Body

2.1. Material and Methods

Type of study is quasi experimental type of study. Samples

were selected through Purposive Sampling. Subjects were

taken from hospitals& clinics in & around Ludhiana. 30

subjects both males and females with age group between 45-

60 years who were having stroke for at least 6 months and

who were able to perform 10-Meter Walk Test. Mini -Mental

State Examination (MMSE) minimum score 24 and Modified

Ashworth Scale (MAS): Grade 1+, 2 were taken as samples.

Subjects with Perceptual disorders, Recurrent stroke having

past or present neurologic disorder other than stroke.

Subjects with visual and auditory impairment or with the

history of any orthopedic conditions interfering with gait.

Subjects with Sensory impairments involving lower limb and

Subjects withCardiovascular disorders and Respiratory

disorders were excluded from the study.

2.2. Procedure

30 subjects with stroke were selected and divided into two

groups. Group A and Group B of 15 subjects in each. Ethical

and informed consents were obtained. The subjects were

assessed and baseline measurement were taken using the ink

foot-print record method before commencement of the

therapy, by measuring the gait parameters i.e. step length,

stride length, gait speed, cadence on a 10 meter walk way

with a plain chart paper on its surface. Patients were

instructed to step on an ink water and were asked to walk on

chart sheet prior two steps were taken on ground. The

footprints from the sole of the feet were produced on the

paper as the patients walked from one end of the walkway to

the other. The measurement of step length and stride length

were taken. [14] The subjects were instructed to walk 14m at

a comfortable speed and were timed using a stop watch over

middle 10m to measure gait speed. [15] For the measurement

of cadence, patients were instructed to walk for 1minute and

step were recorded.

Group A included 15 subjects who were given dual task

training. In this conventional physiotherapy as muscle

strengthening of affected lower limb and balance training

were given to the patient prior to dual task training for 15

minutes.

Dual task training group were instructed to perform motor

and cognitive dual task gait training (MCDGT) while

walking on floor. In motor dual task gait training (MDGT)

patients were instructed to perform 5 types of motor dual

tasks. The tasks were ‘tossing up and catching a ball’,

‘rehanging loops on different hooks’, ‘doing up buttons after

unbuttoning’, and ‘holding a glass of water without spilling

it’, ‘receiving and returning a glass of water’. [16] In

cognitive dual task gait training (CDGT) patients were

instructed to perform 5 types of cognitive dual tasks. The

tasks were ‘discerning colours’, ‘mathematical subtraction’,

‘verbal analogical reasoning’, ‘spelling words backward’,

‘counting backward”. Duration of dual task training for both

cognitive task and motor task was 30 minutes. Each task was

practiced for 3minutes a session, 3 sessions per week for 8

weeks.

Group B included 15 subjects who were given task

oriented training. In this conventional physiotherapy as

muscle strengthening of affected lower limb and balance

training were given prior to task oriented training for 15

minutes.

Task oriented training group were instructed to

perform10 tasks. These were (1) step ups (stool of constant

step height of 15cm i.e 6” (length18” and breadth 13”), (2)

balance beam, (3) kicking a ball, (4) stand up and walk, (5)

obstacle walking, (6) tandem walk, (7) walk and carry (any

object), (8) speed walk, (9) walk backwards, and (10) stairs.

Duration of task oriented training is 30 minutes. Each task

was practiced for 3 minutes a session, 3 sessions per week

for 8 weeks.

Post test data measurement were taken using the ink foot-

print record method after commencement of the therapy, by

44 Amandeep Singh et al.: Comparison of Dual Task and Task Oriented Training Programme on Gait in Chronic Stroke

measuring the gait parameters. The data was collected,

compiled and analyzed.

3. Results

Data was meaningfully assorted through calculation of

Mean and Standard Deviation. Later on Paired‘t’ test was

applied for comparison within Group A and Group B for Gait

Parameters i.e gait speed, cadence, step length, stride length.

Thereafter unpaired ‘t’test was applied for comparison

between Group A and Group B for gait parameters. The level

for Significance was fixed at p<0.05.

Table 1 and Figure 1 shows UnPaired ‘t’ test result of Gait

Speed between Group A and B.. The Mean±SD value for Pre

test of Gait speed of Group A was 0.37±0.104 and pre test of

Group B was 0.37±0.119. The Mean and SD value for Post

test of Gait Speed of Group A was 0.52±0.140 and Post test

of Group B was 0.63±0.126. The ‘t’ value for Pre test

comparison between Group A and Group B was 0.114, which

was statistically non significant, at p>0.05 and Post test

comparison between Group A & Group B was 2.276, which

was Statistically Significant, at p<0.05.

Table 2 and Figure 2 shows UnPaired ‘t’ test result of

Cadence between Group A and B.. The Mean±SD value for

Pre test of Cadence of Group A was 57.07±21.674 and pre

test of Group B was 61.33±23.454. The Mean and SD value

for Post test of Cadence of Group A was 80.93±14.916 and

Post test of Group B was 92.40±10.418. The ‘t’ value for Pre

test comparison between Group A and Group B was 0.517,

which was statistically non significant, at p>0.05 and Post

test comparison between Group A & Group B was 2.441,

which was Statistically Significant, at p<0.05.

Table 3 and Figure 3 shows UnPaired ‘t’ test result of Step

Length between Group A and B.. The Mean±SD value for

Pre test of Step Length of Group A was 7.64±2.180 and pre

test of Group B was 8.08±2.562. The Mean and SD value for

Post test of Step Length of Group A was 12.14±1.732 and

Post test of Group B was 13.69±1.880. The ‘t’ value for Pre

test comparison between Group A and Group B was 0.507,

which was statistically non significant, at p>0.05 and Post

test comparison between Group A & Group B was 2.353,

which was Statistically Significant, at p<0.05.

Table 4 and Figure 4 shows UnPaired ‘t’ test result of

Stride Length between Group A and B. The Mean±SD value

for Pre test of Stride Length of Group A was 18.62±4.008

and pre test of Group B was 18.76±3.686. The Mean and SD

value for Post test of Stride Length of Group A was

24.51±4.137 and Post test of Group B was 28.78±2.342 The

‘t’ value for Pre test comparison between Group A and Group

B was 0.100, which was statistically non-significant, at

p>0.05 and Post test comparison between Group A & Group

B was 3.476, which was Statistically Significant, at p<0.05.

Table 5 and Figure 5 shows UnPaired ‘t’ test result of Age

between the Group A and Group B. The mean±SD value for

Group A was 53.53±3.681 and for Group B was 53.13±4.103.

The ‘t’ value for comparison of Age between Group A and

Group Bwas 0.281, which was Statistically non Significant,

at p>0.05.

Figure 1. Comparison of Gait Speed between the Group A and B.


Figure 2. Comparison of Cadence between the Group A and Group B.

Figure 3. Comparison of Step Length between the Group A and Group B.


Figure 4. Comparison of Stride Length between the Group A and Group B.

Figure 5. Comparison of Age between the Group A and Group B.


Table 1. Comparison of Gait Speed between the Group A and Group B.

UnPaired ‘t’ test

Baseline (Pre) Readings Comparison Post Readings Comparison

Gait Speed Gait Speed

Group A Group B Group A Group B

Mean 0.37 0.37 0.52 0.63

Standard Deviation 0.104 0.119 0.140 0.126

‘t’ value 0.114 2.276

t0.05 2.05

Results Non-Significant Significant

p>0.05 Non Significant.

p<0.05 Significant.

Table 2. Comparison of Cadence between the Group A and Group B.



Cadence Cadence


Mean 57.07 61.33 80.93 92.40


‘t’ value 0.517 2.441

t0.05 2.05

Results Non-Significant Significant


p<0.05 Significant.

Table 3. Comparison of Step Length between the Group A and Group B.



Step Length Step Length


Mean 7.64 8.08 12.14 13.69


‘t’ value 0.507 2.353

t0.05 2.05

Results Not-Significant Significant


p<0.05 Significant.

Table 4. Comparison of Stride Length between the Group A and Group B.



Stride Length Stride Length


Mean 18.62 18.76 24.51 28.78


‘t’ value 0.100 3.476

t0.05 2.05

Results Not-Significant Significant


p<0.05 Significant.

Table 5. Comparison of Age between the Group A and Group B.

UnPaired ‘t’ test Age

Group A Group B

Mean 53.53 53.13

Standard Deviation 3.681 4.103

‘t’ value 0.281

t0.05 2.05

Results Not Significant


p<0.05 Significant.


4. Discussion

Gait is a complex process and stroke patients have a

characteristic gait pattern. Thus, gait speed assessment can be

used as a criterion of functional recovery for stroke patient.

The standard of independent gait ability and increase in gait

speed are the final steps of stroke rehabilitation, providing

the chance for stroke patients to return to their community

and actively participate in social activities. [19] In this study,

The data was analyzed through Paired ‘t’ test for comparison

within the dual task training (Group A), which gave ‘t’ value

for gait speed8.095, cadence 9.994, step length 8.768, stride

length 6.285, which was statistically significant andtask

oriented training (Group B), which gave ‘t’ value for gait

speed 10.724, cadence 6.094, step length 6.618, stride length

7.988 which was statistically significant. There after

unpaired‘t’ test was applied for comparison between Group A

and Group B which gave ‘t’ value for gait speed is 2.276,

cadence 2.441, step length 2.353, stride length 3.476 which

were statistically significant. This above values showed that

after intervention there was significant improvement within

both the Groups i.e dual task training and task oriented

training but when we compare both groups task oriented

training has shown more improvement in gait of chronic

stroke patients than the dual task training. Irrespective to the

technique both groups showed significant improvement in

gait which can be explained on the basis of phenomena of

neural plasticity following brain lesion, supported by various

studies on brain plasticity. [18] Repetitive exercises and

training in real life task following stroke may be a critical

stimulus for the making of new more effective functional

connections within remaining brain tissue. Training and

practice using methods that facilitate motor relearning would

be essential to the formation of new functional connections.

Neural system is inherently flexible adaptive and responding

according to many factors like patterns of use. The complex

organization provides the foundation for functional plasticity

in motor cortex. Cortical representation reflects changes

associated with skill development and provoked by active,

repetitive, training and practice. So it can be because of

specificity of training with respect to different environmental

conditions as practiced in both the techniques showed

improvement in gait. [19]

Task oriented training is based on the motor learning

theory. [20] According to this theory, for doing any task

attention is directed to the desired outcome and critical task

elements. This helps the learner to develop an internal

cognitive map or reference of correctness. Task oriented

training prevents learned nonuse of the involved segments

while stimulating central nervous system recovery. [21]

Learning comes from an interaction and strengthening among

multiple systems and there may be strong neural connections

between related systems that can be crudely viewed as

representations. This internal representation needs to be

matched to the external environment and functional

movement likely emerges as a result of this interaction. [22]

Motor learning involves a very important component of

analysis of task before actually performing it. Tasks are

broken down in to discrete parts during analysis. [21] This

analysis leads to in depth cognitive processing of the task

leading to enhanced functional connections in the motor

cortex. [19] These functional connections in motor cortex

helps in learning process that depends on length of time

given to the task during practice, the nature of the task, prior

experience, motivation of the learner & feedback. [21]

Stronger perceptual trace developed in motor cortex through

practice improves capability of learner to use close loop

process for learning movements required during gait cycle, in

turn improve gait parameters.

Task oriented training involves various tasks which are

representation of real life activitities which are practiced on

day to day basis, this practice leads to more enhanced

cognitive map in the motor cortex. [19] In the study of task

oriented purposed that outcomes of a task are dependent on

principles of specificity, variability, repetition and intensity.

The principle of variability and specificity leads to overall

improvement in performance of task, as it gives an

opportunity to the person to practice a task in the variety of

contexts. Hence improvement in retention of skills required

for a specific activity, which is gait in this study. [23] The

reason which can be attributed for significant improvement in

dual task group might be that, dual task training, provides

information regarding restoration of automatism of balance

control by influencing the reorganization process of central

nervous system with respect to postural stability. [24] Dual

task training is based on the dual task interference theory.

Lateral prefrontal cortical structures are recruited when dual

tasking involves more serial response selection, whereas

striatal structures of the basal ganglia are recruited when

there is a more parallel response selection process. The role

of basal ganglia is recognized in the model of prioritization

for dual task interference which plays important role in

habitual responses (i.e well practiced and more automated

tasks that require relatively little attention resources) which

dominate in situation where one must act quickly and that

habitual responses are characterized by parallel processing.

[10] Dual task the internal focus of attention, concentrating

on the movement itself, during the performance of a motor

task inhibits self-operating postural control due to conscious

control of the posture, while the external focus of attention,

concentrating on the result of the movement during the motor

task, promotes self operating postural control. Hence while

perfoming a dual task both of internel and external focus of

attention determines the final outcome of the task. [9] Dual

task performance requires a high level of concentration,

which results in decreased gait ability in stroke patients.

Structural problems within the frontal lobe and motor areas

resulting from a stroke result in reduced concentration and

increased cognitive motor interference. Consequently,

concentration during performance of dual tasks is directed

towards the cognitive component of the task while

concentration on other task components decreases. [8]

Comparison when done between both the groups task

oriented training comes out to be better in improving various


outcomes of the gait. This result could be explained on the

basis of Task Automatization Hypothesis, which states that

practicing only one task at a time allows participants to

automatize the performance of individual tasks. As a result,

the processing demand required to perform the tasks is

decreased, leading to a more rapid development of skills.

[25] Reason which may be attributed for task oriented

training group to show significant improvement is that

subjects might have concentrated only on the task that were

performed by them. Full attention was given to the task only.

To minimize the changes and to promote recovery,

extended practice requiring the patient’s active participation

is necessary. Task oriented training incorporates practice that

is supervised and structured to involve functional goals and

realistic tasks which could be the link factor for better

outcomes of task oriented training. [11] This attempt of

comparison among the two techniques suggest task oriented

training programme to be a better Technique for improving

gait parameters in chronic stroke. This current study would

provide a justification that task oriented training programme

could be one of the efficient treatment technique for

improving the gait in chronic stroke.

5. Conclusion

This study concluded that there was significant difference

between the effect of dual task and task oriented training

programme on gait in chronic stroke. Pre treatment data was

taken using gait parameters i.e gait speed, cadence, step

length, stride length as outcome measures. Group A

performed dual task training and group B performed task

oriented training. Post treatment data was collected and

analysed. But there were some drawbacks likesmall sample

size, all gait parameters were not assessed and only middle

age group were considered. Stroke is one of the main

neurological conditions which affect the gait pattern but there

are many other neurological conditions with Gait pathology

other than stroke which can be considered for seeing the

effect of dual task and task oriented technique.

Abbreviation

WHO World Health Organization

DT Dual Task

MMSE Mini -Mental State Examination

MAS Modified Ashworth Scale

MCDGT Motor and Cognitive Dual Task Gait Training

MDGT Motor Dual Task Gait Training

CDGT Cognitive Dual Task Gait Training

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